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Canadian Journal of Cardiology
Clinical Research| Volume 34, ISSUE 3, P319-329, March 2018

Associations Between Complex PCI and Prasugrel or Clopidogrel Use in Patients With Acute Coronary Syndrome Who Undergo PCI: From the PROMETHEUS Study

Published:December 27, 2017DOI:https://doi.org/10.1016/j.cjca.2017.12.023

      Abstract

      Background

      Potent P2Y12 inhibitors might offer enhanced benefit against thrombotic events in complex percutaneous coronary intervention (PCI). We examined prasugrel use and outcomes according to PCI complexity, as well as analyzing treatment effects according to thienopyridine type.

      Methods

      PROMETHEUS was a multicentre observational study that compared clopidogrel vs prasugrel in acute coronary syndrome patients who underwent PCI (n = 19,914). Complex PCI was defined as PCI of the left main, bifurcation lesion, moderate-severely calcified lesion, or total stent length ≥ 30 mm. Major adverse cardiac events (MACE) were a composite of death, myocardial infarction, stroke, or unplanned revascularization. Outcomes were adjusted using multivariable Cox regression for effect of PCI complexity and propensity-stratified analysis for effect of thienopyridine type.

      Results

      The study cohort included 48.9% (n = 9735) complex and 51.1% (n = 10,179) noncomplex patients. Second generation drug-eluting stents were used in 70.1% complex and 66.2% noncomplex PCI patients (P < 0.0001). Complex PCI was associated with greater adjusted risk of 1-year MACE (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.20-1.39; P < 0.001). Prasugrel was prescribed in 20.7% of complex and 20.1% of noncomplex PCI patients (P = 0.30). Compared with clopidogrel, prasugrel significantly decreased adjusted risk for 1-year MACE in complex PCI (HR, 0.79; 95% CI, 0.68-0.92) but not noncomplex PCI (HR, 0.91; 95% CI, 0.77-1.08), albeit there was no evidence of interaction (P interaction = 0.281).

      Conclusions

      Despite the use of contemporary techniques, acute coronary syndrome patients who undergo complex PCI had significantly higher rates of 1-year MACE. Adjusted magnitude of treatment effects with prasugrel vs clopidogrel were consistent in complex and noncomplex PCI without evidence of interaction.

      Résumé

      Contexte

      Les puissants inhibiteurs de P2Y12 peuvent procurer des bienfaits accrus contre les accidents thrombotiques dans le cadre d’une intervention coronarienne percutanée (ICP) complexe. Nous avons étudié l’utilisation du prasugrel et les résultats en fonction de la complexité de l'ICP, de même que nous avons analysé les effets du traitement selon le type de thiénopyridine.

      Méthodologie

      PROMETHEUS était une étude observationnelle multicentrique visant à comparer le clopidogrel au prasugrel chez des patients atteints d’un syndrome coronarien aigu qui ont subi une ICP (n = 19 914). L'ICP complexe était définie comme une ICP à l’artère coronaire gauche, une lésion de bifurcation, une lésion calcifiée modérée ou grave ou l’installation d’une endoprothèse d’une longueur totale d’au moins 30 mm. Les événements cardiaques indésirables majeurs (ECIM) comprenaient les décès, les infarctus du myocarde, les accidents vasculaires cérébraux ou les revascularisations non prévues. Les résultats ont été corrigés au moyen du modèle de régression de Cox à plusieurs variables pour tenir compte de l’effet de la complexité de l'ICP ainsi que d’une analyse stratifiée selon la propension pour tenir compte de l’effet du type de thiénopyridine.

      Résultats

      La cohorte de l’étude comprenait 48,9 % (n = 9735) de cas complexes et 51,1 % (n = 10 179) de cas non complexes. Des endoprothèses médicamentées de deuxième génération ont été utilisées chez 70,1 % des patients subissant une ICP complexe et chez 66,2 % des patients subissant une ICP non complexe (p < 0,0001). L'ICP complexe a été associée à un risque corrigé accru d'ECIM après un an (rapport de risques instantanés [RRI], 1,29; intervalle de confiance [IC] à 95 %, 1,20 à 1,39; p < 0,001). Le prasugrel a été prescrit à 20,7 % des patients ayant subi une ICP complexe et à 20,1 % des patients ayant subi une ICP non complexe (p = 0,30). Comparativement au clopidogrel, le prasugrel a considérablement réduit le risque corrigé d'ECIM après un an dans les cas d'ICP complexes (RRI, 0,79; IC à 95 %, 0,68 à 0,92), mais pas dans les cas d'ICP non complexes (RR, 0,91; IC à 95 %, 0,77 à 1,08), bien qu’il n’y ait eu aucun signe d’interaction (p interaction = 0,281).

      Conclusions

      Malgré l’utilisation de techniques contemporaines, les patients atteints d’un syndrome coronarien aigu qui subissent une ICP ont affiché un taux considérablement accru d'ECIM après un an. L’ampleur corrigée des effets thérapeutiques du prasugrel par rapport au clopidogrel a été comparable dans les ICP et non complexes, sans signe d’interaction.
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